Tuesday, April 03, 2007

TB patient in jail

I believe one of the reasons many physicians take up anonymous blogging is to complain about non-compliant patients. If a patient does not follow my recommendations, it's pretty simple. We agree to disagree and I ask the patient to find another physician. Most of the time, that works out.

Here's a story which I find very interesting. It definitely has public health implications, and is sparking quite a debate about an individual's civil rights verses the health of the public.

Robert Daniels has been in an Arizona jail since last summer. (Associated Press) He has not been charged with a crime, but what he does have is a drug resistant case of tuberculosis. It is so resistant, that it is considered untreatable. Why is he in jail? Here's why:

County health authorities obtained a court order to lock him up as a danger to the public because he failed to take precautions to avoid infecting others. Specifically, he said he did not heed doctors' instructions to wear a mask in public.

Though Daniels' confinement is extremely rare, health experts say it is a situation that U.S. public health officials may have to confront more and more because of the spread of drug-resistant TB and the emergence of diseases such as SARS and avian flu in this increasingly interconnected world.

"Even though the rate of TB in the U.S. is at the lowest ever this last year, we live in a globalized world where, if anything emerges anywhere, it could come to our country right away," said Mark Harrington, executive director of the Treatment Action Group, an American advocacy group.

So, the debate is what to do with this guy. On the one hand, you have a non-compliant patient who refuses to be treated. An individual has the right to refuse treatment, right? And, on the other hand, you have someone with a highly contagious disease which is incurable. You let this guy out of jail, and he will definitely infect the public, and then what do you do?

I'm all for personal sovereignty, but if this guy was in my little county jail, there would be no way that I would let this guy out. I mean, he is choosing not to be treated. There are consequences to choices, and I think remaining locked up is a small price to pay for preventing a TB epidemic.

23 comments:

I don't know that jail really is the right place for this guy, though. I mean, maybe he'd be better off in a hospital; certainly in jail his MDR-TB could spread unchecked, and that's not even fair to the other prisoners.

Just for arguments sake, say this guy does go to the hospital. Then, refusing treatment, he would sign himself out against medical advice, and then be walking the streets of your town.

Now what would people want to do? What would happen when the first child got infected? The first elderly patient or nursing home got infected. The first cancer patient or other immunocompromised person? Just something to think about....

Sounds like he wasnt refusing treatment...(because the article says that he has a form of TB that is hard to treat with drugs) but just that he wasnt wearing a mask when out in public. I really dont think we have enough information on what happened via this article to know exactly what happened. I think that yes, if he was a threat, they should quarantine him, but he doesn't belong in jail.

I think there is a fine line between someone taking their own health care into their hands and making choices for themselves (because they know their bodies best) and their kids and calling a disagreement "non compliant". I've heard of too many situations where a doctor labeled someone (no, not me) that just asked questions or wanted a different treatment labeled as such ...and then been unable to find another doctor because those words grace their files.

I know this case has public health issues-but as I said, I really dont get from the story he was "non compliant" in wanting his disease treated ...he just didn't/forgot?/wasnt wearing his mask in public. If he was from Russia as the article states, isnt it very possible he just didn't understand what he was being told to do? Muddy

I do admit that I don't have all the facts. All my information is from this article, and I probably should have done a little more research.

According to the article, he's been in jail since last July. One would think that a sufficient explanation to this gentleman should have been made by now.

As far as quarantining this person, if not jail, then where? In a hospital: Wouldn't his movements be restricted there as well to decrease chance of infecting others? Wouldn't that feel like jail?

At home: How would your neighborhood react if this guy moved in there?

I'm not trying to be difficult. This is an interesting debate whose issues we may have to deal with down the road.

How about this? What if this guy was the first case of bird flu in the United States? Then what would we do as a society? There is no good treatment for this yet. Would we quarantine this guy? Interesting....

At least in a hospital, they would have better means of caring for him...not just the illness, but the basic human needs such as bathing. (The article said he had not been allowed a real bath-and had only been given wipes) IMO, it would be more humane... It doesnt even sound as if he is getting equal treatment within the jail walls as other inmates do.

It seems to me as we face more diseases that are considered "incurable" like this man's TB-we'd see sanatoriums like days of old rebuilt or reopened until cures are found to at least deal with the problems that face us as a community. If we dont have other solutions (beyond locking up someone as if they were a criminal) then we are failing one another as a society and not dealing with problems effectively. (as was hinted at during the "Ashley Treatment" debate here on your blog a few months ago)Muddy

What I'm confused about is that it says he has "drug resistance TB" It further states his TB is so drug resistant as to be untreatable. That doesn't sound like he is refusing treatment. However, if he is refusing to protect the public by wearing masks when out or taking other precautions then that would also be non-compliant, wouldn't it?

I dont know Doc. what they should do with him. I have a problem with him being in fail and a problem with him being out on the streets and a problem with him being in a hospital. None of them sound like a good option. Do we not have any TB hospitals at all anymore?

We were unfortunate here in Toronto during the SARS crisis where a lot of people (mostly health care workers) died and a lot more terribly ill. Anyone who was remotely in the chain of infection had to be quarantined and wear a mask. That's just the way it was. Unless this gentleman complies with the masking rule, then too bad so sad, stay in jail. When you have an disease that is incurable or highly infectious it is incumbent upon you to protect the rest of society. Same with aids, you have it, you wear a condom you don't expose others,if you do you go to jail period, end...ciao

When I read about this on CNN I have to admit I was surprised that a man could be placed in jail for not wearing a mask. Not sure that jail is the most appropriate place for him. However, that being said I do believe that is a matter of public health and it isn't appropriate to let a man walk about the world knowing that he may be spreading TB. Again, not sure jail is an appropriate place for him but I don't have any suggestion for a better place and I glad that officials are considering the health of the general public. Does raise some interesting civil rights questions though.

The jail was just a place that had the tools of isolation needed. The media is exploiting the use of the jail to sensationalize this case and give it added emotional impact. The patient isn't 'in' jail, he's being quarantined in an appropriate facility that also happens to serve as a prison.

Quarantine is an essential tool for guarding the public health. This is very much a case of the good of the many trumping the inconvenience of the few. Don't kid yourselves, if he was walking around in public without correct precautions people (Children, the elderly, etc.) would die as a result.

What about house arrest? Don't they do that with prisoners these days, too? That would be the most humane, and make the most sense. He won't follow instructions and wear a mask in public, therefore he doesn't get to be in public. Easy-peasy!

Note the quotes, 'in' in the sense of being arrested or a usual inmate. He's not in general population. If there were a quarantine facility available that didn't also serve as a prison I'm sure they'd use it specifically to avoid media abuse of the idea of jailing sick people.

As far as house arrest, there are still precautions he has to be trusted to take even in his own home. If he infects his wife, child, or any other visitor then it's just the same as having let him wander the streets free. He proved unreliable in observing very reasonable precautions, and so extreme measures were taken to guard the public health.

I have no problems with the guy being in jail - I am very much for the right of informed refusal but not when there is a clear threat to the health of others. What I have problem with in this case is that the guy is not allowed to bathe, not allowed to watch TV, not allowed to use computer or the phone (the article doesn't mention books, but he says he has virtually nothing to do but stare at the walls). Another article I read said that at some point nurses felt sorry and gave him a computer, but the guards took it away.

This sounds like cruel and unusual punishment. Why can't he have TV or talk to his family on the phone?

When I was an RN in Taiwan years ago, TB was taken very seriously, as it's highly contageous and could cause serious public health problems. A few years ago when SARS killed many people in Asia, we were very worried about our parents and other family members who were living there & working in healthcare.

I think TB, just like SARS and avian flu, can't be taken lightly. I agree that this person should be quarantined if he really refused to wear a mask to protect others; however, I'm not sure if jail is the right place for him. Since I'm no longer in healthcare, I'm not sure about the system now. I was wondering about the same thing that Cathy asked- don't we have TB hospitals in US (or hospitals that specialize in infectious diseases)? I think that's where this person belongs.

I think he should be put in a quarantined area, not in a state prison or something. By drug-resistant TB, it just meant that the usual medications used for TB are not effective to treat his disease anymore so he has to take 2nd line medications. I practice in the Philippines and we do have plenty of multiple drug-resistant cases here. Usually they are treated in the hospitals. So far in my practice, I haven't encountered a really stubborn, non-compliant MDR-TB patient yet. But, yeah, there are a LOT of noncompliant patients. Not just because they do not understand the consequences. I think it is their REFUSAL to understand the situation.

Of course, in the quarantine, he must be treated as humanely as possible. However, in this case that the consequences of his refusal to be treated has been explained to him (well, that's the impression that I got from this post) and still he refused, then the government should do something about it. He's a danger to the society as a whole, moreso to his family. I think the whole dilemma should also be explained to his family.

We need clarification on the terms being tossed around here. First off untreatable or incurable disease: Would this include AIDS? Was this man ordered to wear a medical mask around? Because if he was ordered to that would be like ordering a person with a sexually transmitted disease to wear a condom. In our society with our increased promiscuity a person with AIDS could be as much of a threat as this man with TB would be. Are we going to make everybody with an incurable disease take necessary action to stop its spread and will there be any punishment if they don't obey? It seems something like this could have far reaching implications.

Quarantine may be one thing, but the conditions of that quarantine should be humane. According to both sides in the ACLU lawsuit, the patient/prisoner has been denied contact with his family, showers, or even being allowed outside his room in a supervised or enclosed area.

Even convicted mass murders get better treatment than this. If we are going to keep him in isolation the rest of his life, there needs to be accomodation for simple things like showers, personal hygiene, family visits, and regular exercise outdoors...even if it is in an enclosed area similar to what prisons have.

In checking with published accounts, the patient is being kept in the jail section of the local hospital. He has a 24 hour guard, is under constant video surveillance, and they do not turn out the lights in his room at night. Only recently has he been granted the "right" to have a cell phone and television in his room.

And it has been almost 9 months since he has showered or been outside.

If this is how we hope to protect public health, wouldn't it be more humane to put him against the wall, shoot him, and then burn his body?